Contraception and Unintended Pregnancy in Uganda

• Unintended pregnancy is common in Uganda, leading to high levels of unplanned births, unsafe abortion, and maternal injury and death.

• According to the 2011 Uganda Demographic and Health Survey (DHS), more than four in 10 births are unplanned.1

• Ugandan women, on average, give birth to nearly two children more than they want (6.2 vs. 4.5). This difference—which represents one of the highest levels of excess fertility in Sub-Saharan Africa—illustrates just how difficult it is for women to meet their fertility desires.1

UNINTENDED PREGNANCY IS THE CAUSE OF MOST ABORTIONS

• Ugandan women from all socioeconomic and demographic backgrounds experience unintended pregnancies, and thus have abortions. Their experiences, however, vary considerably. Compared with their poorer counterparts, women who are well off generally have access to a wider range of providers, and are more likely to be able to visit doctors, nurses and clinical officers, some of whom may be trained and able to provide safe procedures.2

• Poor and rural women, whose access to skilled providers is limited by financial constraints and geographic distance of services, often must resort to obtaining abortions performed by untrained providers using unsafe methods or attempt to self-induce an abortion.2,3

• Because most pregnancies that end in abortion are unwanted, nearly all injury and death resulting from unsafe abortion can be avoided by preventing unintended pregnancies.

• In 2008, the Ugandan Ministry of Health estimated that unsafe abortion accounted for 26% of the country’s maternal deaths.4,5 This proportion is considerably higher than the World Health Organization’s estimate for abortion-related deaths in Eastern Africa (18%).6

IN UGANDA, CONTRACEPTIVE USE IS LOW…

• The high levels of unintended pregnancy and unplanned births in Uganda can be attributed primarily to nonuse of contraceptives by women who do not want a child soon.

• Married women’s use of modern contraceptives has increased significantly in recent years, nearly doubling (from 14% to 26%) between 2000 and 2011.1,7 However, modern contraceptive use remains too low to address the high rate of unintended pregnancy.

• Contraceptive use has not risen in the past decade among sexually active unmarried women—38% were using a modern contraceptive method in 2000, and the same proportion was doing so in 2011.1,7

• Use of modern methods varies greatly according to women’s social and economic status. In 2011, only 13–15% of Uganda’s poorest and least educated married women used modern contraceptives, compared with 37–39% of the wealthiest and most educated women. A greater proportion of urban married women used modern contraceptives compared to their rural counterparts (39% vs. 23%).1

…AND UNMET NEED FOR MODERN METHODS IS HIGH

• In 2011, the proportion of married women who had an unmet need for contraception—that is, they did not want a child soon or wanted to stop childbearing altogether, but were not using any type of contraceptive—was one in three, among the highest levels in Sub-Saharan Africa.1

• Most married women with an unmet need for modern contraception (62%) want to space or delay births, but a significant proportion (38%) have achieved their fertility goals and want to stop childbearing altogether.1

• Despite their higher levels of contraceptive use, sexually active unmarried women have even higher levels of unmet need for contraception (43%) than do married women (33%), which may reflect unmarried women’s stronger motivation to avoid pregnancy.1

• Unmet need is higher among rural, less educated and poor women than among women who live in urban areas, have at least a secondary education or are better off economically, respectively.1

MANY BARRIERS TO CONTRACEPTIVE USE EXIST

• There are many reasons why women do not use contraceptives. Lack of access to family planning services and information is often a barrier—rural women with unmet need for contraception are more than twice as likely as their urban counterparts to cite lack of access as a reason for not using contraceptives.1

• Male partners also may influence whether a woman will practice contraception. One qualitative study found that some Ugandan men believed that contraceptives can cause health problems, such as infertility and cancer, while others felt that contraceptive use might cause women to have extramarital affairs.8

• Among married women with unmet need, commonly cited reasons for not using contraceptives include personal or partner opposition to use (26%), breastfeeding or having recently given birth (26%) and fear of side effects (22%). These reasons suggest that many women lack accurate information about family planning, including its mechanisms of action, safety, side effects, efficacy and ease of use.1

• Lack of availability of a range of contraceptive methods, or of any at all, make it difficult for a woman to use a method continuously and to obtain a method that is appropriate to her needs.9

• According to the 2011 DHS, one of the most common reasons that unmarried, sexually active 15–24-year-old women cite for not using a method is that they are not married, which underscores the impact of the stigma surrounding sex outside of marriage.1

CONTRACEPTIVE USE PROMOTES HEALTH AND SAVE LIVES

• The health benefits of contraceptive use are substantial. Contraceptives prevent unintended pregnancy, reduce the number of abortions, and lower the incidence of death and disability related to complications of pregnancy and childbirth.

• According to a 2009 study by the Guttmacher Institute, contraceptive use in Uganda averts approximately 490,000 unintended pregnancies and 150,000 induced abortions each year.10

• Meeting just half of women’s unmet need would have resulted in 519,000 fewer unintended pregnancies in 2009, which in turn would have led to 152,000 fewer abortions and saved the lives of 1,600 women.

• If all unmet need for modern contraceptive methods in Uganda were satisfied, maternal mortality would drop by 40%, and unplanned births and induced abortions would decline by about 85%.

FAMILY PLANNING SAVES MONEY

• According to the 2009 study, the cost of providing pregnancy-related medical care would fall by US$81 million if just half of unmet need for modern contraception were met. It would decline by US$162 million if all unmet need were eliminated.10

• This means that for every additional dollar spent providing family planning services in Uganda, more than three dollars would be saved in pregnancy-related medical care.

• The cost of providing postabortion medical care is five times the average annual cost of providing modern contraceptive services.

• In addition to the financial savings, significant societal benefits would also result if all women had the ability to plan and space their pregnancies as desired. For example, women’s educational opportunities, as well as their ability to enter the workforce and thus contribute to family income, would be enhanced.

RECOMMENDATIONS FOR ACTION

• Eliminating barriers to family planning services will reduce unmet need for contraception. The government should ensure that free or affordable public-sector contraceptive services reach all women, especially those who are poor, are young or live in rural areas.

• Programs should offer comprehensive family planning services—that is, provide counseling, information and a wide range of contraceptive methods—to enable women to choose the method the best meets their needs, to use methods effectively and to switch methods when desired.

• Policies and programs should prioritize youth-friendly services that offer confidential reproductive health counseling and information as well as provision of family planning methods.

• The quality of postabortion care services needs to be improved, and the scope of such services needs to be expanded. Because unsafe abortion continues to cause serious health complications, postabortion care will remain a vital part of maternal healthcare. To adequately address the need for services in all parts of the country, more providers, including midlevel ones, must be trained to the extent possible to provide comprehensive postabortion care, particularly the least invasive recommended treatments (for example, manual vacuum aspiration and medication abortion for incomplete first-trimester abortions). Providers should also be trained to provide services in a sensitive and nonjudgmental manner.